Cent Eur J Nurs Midw 2017;8(2):632–640

doi: 10.15452/CEJNM.2017.08.0012

ORIGINAL PAPER

COMPETENCIES OF NURSE MANAGERS IN SLOVENIA: A QUALITATIVE AND

QUANTITATIVE STUDY

Karmen Erjavec1,2, Jasmina Starc1,2

1
Institut for Research and Development FPUV, Faculty of Business and Management Sciences Novo mesto, Slovenia
2
Institut for Research and Development FZV, Faculty of Health Sciences Novo mesto, Slovenia

Received August 26, 2016; Accepted December 15, 2016. Copyright: This is an open access article distributed under the terms of the
Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Abstract
Aim: The aim of the study is to identify nurse managers’ competencies in Slovenia regarding various healthcare organisations,
public and private healthcare sectors, and management levels, as well as the reasons for their differences. Design: The study
was based on quantitative and qualitative research. Methods: An online survey was conducted among 297 nurse managers in
Slovenia, and in-depth interviews with 12 nurse managers were carried out. Results: Managers who worked in nursing homes
were significantly more likely to perceive themselves as being more competent in leadership (p = 0.001) and financial
management (p = 0.004) than their colleagues. Managers who had higher management positions were significantly more likely
to perceive themselves as being more competent in financial management than their colleagues in lower management positions
(p = 0.002). Nurse managers in the private sector perceived themselves to be significantly more competent in financial
management (p = 0.0001). The reasons for nurse managers’ differences in proficiency levels are the degree of job security, and
degree of autonomy and support in the healthcare team. Conclusion: The study identified inadequate nurse manager
competencies, and reflected the needs of nurse managers for designing and providing health management programmes aimed
at enhancing management capacity in the health sector in Slovenia.
Keywords: management, competencies, skills, nurse managers, Slovenia, in-depth interviews, healthcare organisations,
management level.

Introduction strengthen nurse manager competencies (Cathcart,

The changes in health and social environment during
the past two decades have led to the increased
importance of management in the healthcare sector,
regardless of whether it is predominantly tax, social
insurance, or market based. In Slovenia, Central
Europe and, more broadly, in the developed world,
healthcare faces many new challenges, such as aging
populations, a shift from acute illnesses to chronic
conditions, shorter hospitalisations, increased
complexity in clinical nursing practice, higher
expectations of patients, aging of staff base, and
testing and scrutiny of healthcare services (Zavrl
Džananović, 2010; Costa Fernandes, 2013; Prosser,
Olson, 2013; Rigolosi, 2013). Through a systematic
review of 37 studies, Lega, Prenestini, Spurgeon.
(2013) found that management skills are essential for
improving the performance and sustainability of the
healthcare system. Thus, a reform of knowledge
management in healthcare is crucial, and serves to
Corresponding author: Karmen Erjavec, Institut for Research
and Development FPUV, Faculty of Business and Management
Sciences, Na Loko 2, Novo mesto, Slovenia; e-mail:
karmen.erjavec1@guest.arnes.si
Greenspan, Quin, 2010; Pillay, 2010; Kantanen et al.,
2015). However, do nurse managers have enough
competencies to face the challenge of such
demanding responsibilities?
A partial answer to this question can be found
in studies that have examined the proficiency level
of nurse managers in hospitals across the globe, and
identified inadequate nurse manager competencies
(Chase, 2010; McCallin, Frankson, 2010; Pillay,
2010; Kang et al., 2012; Townsend et al., 2012; Luo
et al., 2016; Pihlainen et al., 2016). However, the
question of the proficiency level in nurse manager
competencies in healthcare organisations other than
hospitals has not yet been answered.
In this study, nurse manager competencies represent
knowledge, skills, abilities, and attitudes that are
necessary for nurse managerial levels and tasks
in formal healthcare (Pihlainen et al., 2016). The
definition of competencies has become complex, and
there is no consensus among scholars on nurse
manager competencies (Pillay, 2010; Kantanen et al.,
2015; Pihlainen, 2016). At present, process-based
management with a lean approach, and competency-

© 2017 Central European Journal of Nursing and Midwifery 632

Erjavec K, Starc J.
based management are emphasized (Hakim, 2014;
Pihlainen, 2016). It rests on the assumption that
unlike generic managers, nurse managers require
additional competencies because of the uniqueness
of the healthcare environment and conceptual
philosophy, since nurses have a social responsibility
for the health of individuals, families, and
communities (Pillay, 2010). However, the
competency-based approach to developing nurse
manager competencies has not as yet been
unconditionally accepted, nor have their formal
programs had as significant an influence as informal
approaches (McCallin, Frankson, 2010; Pihlainen et
al., 2016).
Pihlainen et al. (2016) performed a systematic
literature review to identify and describe the
characteristics of nurse manager and leadership
competencies in healthcare. They found that literature
is surprisingly limited, and nurse manager
competencies could be broken down into three main
categories: healthcare context-related, operational,
and general competencies. Nurse manager roles
requiring healthcare context-related competencies
comprise social, organisational, business, and
financial dimensions. Within the category
of operational competencies, they identified process,
operation, clinical, and development competencies to
be important for the managerial role. General
management competencies comprise time
management, interpersonal skills, strategic mindset,
thinking and application skills, and human resource
management in all analysed studies. Chase (1994;
2010) developed a Nurse Manager Competencies
Model that classifies nurse manager competencies
into five main categories: technical skills, human
resource skills, conceptual skills, leadership skills,
and financial management, the key competencies
synthesised by Pihlainen et al (2016). By using
a web-based survey to collect information from
hospital nurse managers, Chase (2010), found that the
highest self-reported nurse manager competencies
ratings included human resource management and
leadership, and the lowest self-reported nurse
manager competencies included conceptual skills and
knowledge.
The position of manager in the organisation is
characterised by varying degrees of rigor and scope
(Lin et al., 2007). In Slovenia, head nurses are the
mainstay of top management. Their primary mission
is to present and represent nursing care in the
healthcare organisation, and formulate its policy, as
well as to develop and coordinate research.
In Slovenia, top management appoints middle
management or the department head, and defines
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
her/his duties and responsibilities (i.e., to organise,
direct, coordinate, and supervise the work of nursing
care in healthcare organisations at the intermediate
level). Lower executive management represents the
one or two levels above the operators. Their work
relates directly to the implementation of operational
management tasks. They are responsible for the
provision of services, and represent the relationship
between the performers and the rest of management,
coordinating the work of their colleagues, and
endeavoring to solve problems promptly. In Slovenia,
this front-line management is mainly carried out at
the operational level, represented by a unit and team
of nurses who lead other nurses, and are responsible
for healthcare (Lorber, 2015). Do nurse managers at
various management levels have different proficiency
levels regarding nurse manager competencies?
There is also a different degree of autonomy between
nurse managers in specific healthcare organisations
(Costa Fernandes, 2013; Prosser, Olson, 2013).
In Slovenia, nurse managers have the greatest
autonomy in nursing homes (residential treatment
centres, and geriatric care facilities), and community
healthcare services within health organisations. They
have the autonomy to organise their work in a team
independently of doctors, and to perform
management activities in the field of nursing, human
resources, and even in financial management, such as
purchasing healthcare materials, without the need for
authorisation from doctors or other professionals
(Zavrl Džananović, 2010; Lorber, 2015). Do nurse
managers in different healthcare organisations have
different proficiency levels in nurse manager
competencies?
Pillay (2010) found that public sector nurse managers
in South Africa assessed themselves as being
relatively less competent than private sector
managers. In Slovenia there are, according to the
Slovenian National Institute for Public Health (2015),
only about 2500 nurses employed in the private
sector, and around 15000 nurses in the public sector
(Slovenian National Institute for Public Health,
2015). Since public sector nurse managers
predominate in Slovenia and other Central European
countries (Waters et al., 2008), the question
of whether Slovenian nurse managers in the private
and the public sector have different proficiency levels
in manager competencies is also relevant.The
existing studies of nurse manager competencies have
analysed only the proficiency level in competencies
of nurse managers working in hospitals (Chase, 2010;
McCallin, Frankson, 2010; Pillay, 2010; Kang et al.,
2012; Townsend et al., 2012; Luo et al., 2016;
Pihlainen et al., 2016), and neglected the question
of why nurse managers differ from each other
633
Erjavec K, Starc J.
regarding their management capacity. This study
aims to close this research gap.
Aim
The aim of the study is to identify nurse managers’
competencies in Slovenia regarding various
healthcare organisations, public and private
healthcare sector, and management levels, as well as
the reasons for their differences.
Methods
Design
The study was based on quantitative and qualitative
research. In the first part of the study, a cross-
organisational questionnaire survey was carried out
to assess managers’ degree of competency. In the
second part of the study, in-depth semi-structured
individual interviews were conducted to identify
clear, accurate, and inclusive opinions based
on personal experience of reasons for different nurse
managers’ self-assessed level of nurse manager
competencies.
Sample
In February 2016, we sent e-mail invitations to
participate to 1,197 nurse managers working in key
public and private medical nursing homes, healthcare
centres, and hospitals as top, middle, and executive
managers, covering all Slovenian regions. Since the
response rate was less than 10%, we resent e-
invitations in April 2016. Data collection was
completed three weeks after the final mailing. The
total response rate was approximately 24.8%.
Since we were attempting to establish reasons why
the competencies among nurse managers differ
regarding healthcare organisations, healthcare sector,
and management levels, a purposeful sample was
used to recruit a sample of 12 nurse managers with
more than two years’ experience as nurse managers
in public and private organisations, hospitals (4),
nursing homes (4), and healthcare centres (4) at
different management levels. In May and June 2016,
interviews were conducted lasting 45 to 120 minutes,
and held in locations chosen by the interviewees,
until conceptual saturation was achieved. Each
interview included the following thematic questions:
“Can you describe any skills usually used in your
management positions?”, and “In your opinion, why
do you usually use some skills more than others?”
Data collection
Our study of nurse manager competencies used
an online survey to collect information from nurse
managers via a self-administered competency
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
instrument. The research review in this area revealed
that Chase’s Nurse Manager Competency Instrument
(2010) was most frequency used, and it appeared to
be most useful for measuring nurse manager
competencies. Reliability and validity assessments
were determined with positive results (Chase, 2010;
2012). We then adjusted it to fit the Slovenian
context. First, the instrument was translated by two
independent translators, then a pre-test with 10 nurse
managers was conducted to ensure the survey was
worded appropriately for cultural and professional
term considerations. The participants
comprehensively excluded two items not appropriate
for the Slovenian context of nurse manager
competencies, i.e. “humour” and “political
processes”. To establish content validity of this
survey instrument, a panel of nurse managers
reviewed the draft of the proposed questions, and
provided feedback to the authors to enhance the
comprehensibility of the questionnaire. Minor
revisions were made to the survey. Nurse managers
were required to rate their proficiency in each of 51
manager competencies items (see Table 1) on a
Likert-type scale from 1 (very poor) to 5 (excellent).
The demographic section of the instrument collected
information regarding organisational and individual
variables. Organisational variables included sector,
management levels, and healthcare organisations.
Individual variables consisted of gender, age,
education, status, and years of employment. The
reliability of the scales was estimated by assessing
their internal consistency using Cronbach’s Alpha,
which demonstrated positive results (“technical
skills”, α = 0.91; “human resource skills”, α = 0.96;
“conceptual skills”, α = 0.98; “leadership skills”, α =
0.92; “financial management”, α = 0.91).
Data analysis
Data for individual variables were summarised using
frequency distribution, and focused on the central
tendency (mean), and dispersion (standard deviation).
The relationships between variables were analysed
using the χ2-test for categorical variables, and one-
way analysis of variance (ANOVA) for quantitative
variables.
The qualitative data were analysed using an
established qualitative analysis technique (for more,
see Patton, 2015). A thematic framework was
developed from the emergent issues. These themes
were used to code the text obtained from the
interview transcripts, allowing for new themes that
emerged. Afterwards, we proceeded to map and
interpret the themes, searching for patterns,
associations, concepts, and explanations, as well as
extracting central ideas, and their key-expressions.
634
Erjavec K, Starc J.
Table 1 List of nurse manager competencies (Chase, 2010)
Competencies
Technical
1. Nursing Practice Standards
2. Nursing Care Delivery Systems
3. Nursing Care Planning
4. Clinical Skills
5. Patient acuity system
6. Infection Control Practices
7. Research and Evidence-Based Practice
8. New Technology
9. Case Management
10. Information Systems and Computers
11. Regulatory Agency Standards
Human Resources
12. Effective Communication
13. Effective Staffing Strategies
14. Recruitment Strategies
15. Retention Strategies
16. Effective Discipline
17. Effective Counselling Strategies
18. Constructive Performance Evaluation
19. Staff Development Strategies
20. Group process
21. Interviewing Techniques
22. Team-Building Strategies
23. Optimism
Conceptual
24. Nursing Theories
25. Administrative/Organisational
26. Strategic Planning/Goal Development
Results
Results of survey
Questionnaires were completed by 297 nurse
managers, eight from nursing homes, 112 from
healthcare centres, and 177 from hospitals. Table 2
shows that most of the respondents at nursing homes
were female (100%), older than 50 years of age
(100%), had a Master’s degree (66.67%), worked in
the public sector (87.5%), and had been working for
more than 30 years (62.5%).
Most of the respondents who worked in healthcare
centres, were also female (95.54%), over 50 years
of age (56.25%), had a Bachelor’s degree (66.07%),
worked in the public sector (76.86%), and had been
working for 20-30 years (33.04%).
Most of the respondents, who worked in hospitals,
were female (90.4%), between 35 to 50 years of age
(44.64%), had a Bachelor’s degree (86.44%), worked
in the public sector (88.14%), and had been working
equally for 10–20 and 20–30 years (24.29%).
Bivariate analysis of categorical variables and sector
showed that there is only one significant relationship
between healthcare organisations and age. Nurse
managers who worked in nursing homes were
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
27. Ethical Principles
28. Teaching/ Learning Theories
29. Quality/Process Improvement
30. Legal Issues
Leadership
31. Decision-Making
32. Power and Empowerment
33. Delegation
34. Change Process
35. Conflict Resolution
36. Problem-Solving
37. Stress Management
38. Research Process
39. Motivational Strategies
40. Organisation Work Units and Workflow Process
41. Policies and Procedures
42. Staff Education
43. Time Management
44. Interdisciplinary Care Coordination
Financial Management
45. Cost Containment and Cost Avoidance Practice
46. Productivity Measurements
47. Operational & Capital Budget Forecasting and Generation
48. Cost Benefit Analysis
49. Unit Budget Control Measures
50. Financial Resource Procurement
51. Financial Resource Monitoring
significantly more likely to be older than their
colleagues in other healthcare organisations (χ2 =
14.22; p = 0.001). There is no significant association
between the healthcare organisations and gender,
education, years of work, and sector.
Table 3 shows the self-assessment of level
of proficiency. As a group, nurse managers from
specific healthcare organisations felt most competent
in terms of healthcare technical skills, followed by
conceptual skills in human resource management,
and leadership. The interviewed nurse managers felt
less competent in terms of financial management.
Table 4 shows the results of bivariate analysis
between categorical variables and self-assessed
proficiency levels. It demonstrates that there were no
significant differences in proficiency among the
different groups in terms of gender, education, and
length of employment. It shows significant
differences in proficiency among nurse managers
regarding age, healthcare organisations, management
levels, and sectors. Older managers felt significantly
more competent in financial management than
younger nurse managers. Managers who worked in
nursing homes were significantly more likely to
perceive themselves to be more competent
635
Erjavec K, Starc J. Cent Eur J Nurs Midw 2017;8(2):632–640

Table 2 Respondents’ characteristics

Medical nursing home Healthcare centre Hospital All
(n= 8) (n = 112) (n = 177) (n = 297)
Frequency % Frequency % Frequency % Frequency %
Gender
women 8 100 107 95.54 160 90.4 275 92.59
male 0 0 5 4.46 17 9.6 22 7.41
total 8 100 112 100 117 100 297 100
Age
< 35 0 0 24 21.43 35 19.77 59 19.87
35–50 2 25 25 22.32 79 44.64 106 35.69
> 50 6 75 63 56.25 63 35.77 132 44.44
total 8 100 112 100 117 100 297 100
Education
secondary 0 0 0 0 2 1.13 2 0.68
bachelor’s 2 33.33 74 66.07 153 86.44 229 77.1
master’s 6 66.67 38 33.93 22 12.43 66 22.22
doctoral 0 0 0 0 0 0 0 0
total 8 100 112 100 117 100 297 100
Sector
public 7 87.5 76 76.86 156 88.14 239 80.47
private 1 12,5 36 23.14 21 11.86 58 19.53
total 8 100 112 100 117 100 297 100
Years of employment
< 10 0 0 22 19.64 34 19.22 56 18.86
10–20 0 0 24 21.43 43 24.29 67 22.56
20–30 3 37.5 37 33.04 43 24.29 83 27.95
> 30 5 62.5 29 25.89 57 32.2 91 30.63
total 8 100 112 100 117 100 297 100

in leadership, and financial management than their
colleagues. Managers who had higher management
positions were significantly more likely to perceive
themselves to be more competent in financial
management than their colleagues in lower
management positions. Nurse managers in the private
sector felt significantly more competent in financial
management.
Results of in-depth interviews
The analysis shows three central ideas which
demonstrate the reasons for differences among nurse
managers according to nurse manager competencies.
Job security. All nurse managers interviewed
mentioned a lack of human and financial resources in
their institutions, which caused a precarious
organizational and financial situation, and prevented
the implementation of adequate healthcare
management in their workplace. Most participants
who worked in the private healthcare sector claimed
that the main way to maximise profits for the owners
is by the understaffing of healthcare teams. Despite
feeling overworked, they train themselves in financial
management, one of the most important skills in the
private sector. Without a high level of proficiency
in financial management competency, they fear they
will lose their jobs. In their opinion, a higher salary is
one of the key reasons why older and experienced
nurse managers leave public sector hospitals, despite
job insecurity. Thus, job insecurity has motivated
participants who work in the private healthcare sector
to become competent in the area of financial
management. I am not employed in a public sector
hospital, where you can do whatever you want, and
cannot be fired. I left the public sector clinic because
I could not change anything. There was indifference
to any changes, and of course, I was not paid a decent
salary for my hard work. You should know that I
work even harder now; yes, I am really overloaded.
And besides all my work, I have to further educate
myself so as not to lose my job. Our owners are only
interested in maximising profits and reducing all
costs. Therefore, I have to be good at finance. (NM2)
Degree of autonomy and executive power in different
healthcare organisations. All interviewed nurse
managers who worked in nursing homes and
community healthcare services within healthcare
centres in the public sector spoke of their regular use
of all management skills in terms of the autonomy to
perform their management role without asking
another professional for authorization. Moreover,
they mentioned their use of executive power

© 2017 Central European Journal of Nursing and Midwifery 636

Erjavec K, Starc J. Cent Eur J Nurs Midw 2017;8(2):632–640

Table 3 Mean values for ratings of proficiency financial resources, I have to be a magician to pay all
Competencies Management levels mean n the bills, and to do the work properly, but I decide
Technical Nursing home 3.67 8 how to spend the money. Well, you see, I have to
Healthcare centre 3.66 112 know how to work with money. Otherwise, I would
Hospitals 3.66 177 not have survived. (NM2)
Total 3.66 297 Lack of support from the healthcare team. The
Human Resources Nursing home 3.38 8 interviewed nurses also stated that support (or lack
Healthcare centre 3.36 112 of support) from the healthcare team members is
Hospitals 3.37 177 a key factor that defines the implementation
Total 3.37 297 of management activities, and the level of proficiency
Conceptual Nursing home 3.64 8 in nurse manager competencies. In the public sector,
Healthcare centre 3.63 112 the economic crisis has resulted in cost reductions
Hospitals 3.63 177 in essential healthcare materials, supplies, and
Total 3.63 297 personnel, as well as huge nursing shortages, an
Leadership Nursing home 3.4 8 unstable work environment, and poorly-paid nursing
Healthcare centre 3.36 112 work. The nurse managers interviewed working
Hospitals 3.35 177 in public sector hospitals and healthcare centres drew
Total 3.37 297 attention to the apathy regarding their work, and lack
Financial Nursing home 3.11 8 of motivation for the performance of managerial
Healthcare centre 2.35 112 duties. However, where nurse managers received the
Hospitals 2.14 177 support of doctor managers, they implemented their
Total 2.53 297
activities conscientiously, and developed their
management skills. Support from team members
motivated them to try to overcome the difficulties
regarding financial resources in comparison with of their position. In particular, participants from
nurse managers in other healthcare organisations, public sector hospitals claimed that doctor managers
especially hospitals. Since they have great decision- had a negative attitude towards them. They did not
making power to dispose of financial resources, they usually respect nurse managers, and did not value
require financial management skills to negotiate the their opinions. Thus, the lack of support from doctors
precarious financial situation. Possessing autonomy discouraged some participants from educating
and executive power motivates the participants to themselves, performing managerial duties, and
educate themselves and become competent in the becoming competent in the areas of financial
area of financial management. In their view, lack of management, and leadership.
autonomy was also one of the key reasons why older I always wonder about the typical pattern when
and experienced nurse managers left public hospitals. an excellent doctor becomes a bad manager who does
In private community healthcare service, nurses have not listen and appreciate me. You cannot work in
significantly more autonomy to perform their work a team that does not support you. Therefore, I am
than nurses working in hospitals. I know that because doing only the most urgent tasks. There is already too
I worked there for more than 20 years. That is why I much administrative work, and not enough time to
left the hospital. I am here on my own, and I am work with patients. Why should I further educate
responsible for my work. Yes, due to a shortage of myself if no one appreciates my efforts? (NM3)

Table 4 Results of ANOVA

Competencies Gender Education Years of Age Healthcare Management Sector
employment organisation level
Technical 0.18 0.68 1.43 1.63 0.31 2.31 0.12
Human Resources 0.76 0.78 2.92 0.33 0.22 0.82 0.01
Conceptual 0.16 0.42 10.02 1.82 0.17 0.77 0.04
Leadership 1.24 0.75 6.11 1.23 13.58** 1.22 0.23
Financial management 0.66 1.79 5.17 9.6* 14.92** 13.92** 18.41***
(F)-value: ***p < .001;**p < .01;*p < .05

© 2017 Central European Journal of Nursing and Midwifery 637

Erjavec K, Starc J.
Discussion
The combination of quantitative and qualitative
methods enabled us to measure nurse managersʼ self-
assessed proficiency level in nurse manager
competencies, as well as the reasons for differences
in these levels.
The nature of the occupation was confirmed as being
predominately female. In addition, most particpants
had a Bachelor’s degree and worked in the public
sector. The most alarming fact was the predominance
of nurse managers older than 50 years (44.44%). This
was also reported by Pilley (2010), who emphasized
that the aging of the nurse base is a trend in all
industrialised countries. The results of the survey also
showed that nurse managers in medical nursing
homes were significantly more likely to be older than
their colleagues in hospitals, which could be
explained by the fact that many older and
experienced nurse managers are drawn to medical
nursing homes due to the greater autonomy, and
higher salaries offered there.
The results of other researchers (Chase, 1994; 2010;
2012; McCallin, Frankson, 2010; Pillay, 2010;
Townsend et al., 2012; Pihlainen et al., 2016),
regarding inadequate nurse manager competencies
were confirmed by our research. The low level
of self-perceived proficiency in all management
categories except the technical in all healthcare
organisations, could be explained by the lack
of systematic management training. Although clinical
aspects of the role are addressed, the management
requirements are more or less neglected (Jennings,
Scalzi, Rodgers, 2007; Bijelic, 2010).
The difference of our results in comparison with
Chaseʼs findings (2010) – the lowest self-reported
nurse manager competencies in the USA included
conceptual skill – could be partially explained by
education, since Slovenian and other Eastern
European healthcare education, in comparison with
the USA, emphasizes conceptual and technical
competencies above financial competencies (Bijelic,
2010).
The results of this study demonstrate a clear
difference between nurse managers in different
healthcare organizations. The difference between
proficiency in leadership and financial management
could be explained by degree of job security, lack
of autonomy, and lack of support from the healthcare
team, factors identified in the in-depth interviews.
The participants working in nursing homes and
community healthcare services within healthcare
centres have greater autonomy and executive power,
and more support from their healthcare teams than
nurse managers working in hospitals. Having
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
autonomy and the support of the healthcare team
motivates and stimulates these participants to educate
themselves in financial management, to try to
overcome the difficulties of the challenging
organisational, and financial situation in healthcare
organisations, particularly characterised by
understaffing, heavy workloads and poor resources.
The difference between sectors and proficiency
in financing could be explained by levels
of autonomy and support from the healthcare team.
However, as our in-depth interviews showed, the
main reason is job insecurity, or, in other words, fear
of losing oneʼs job, which stimulates private nurse
managers to gain proficiency in financial manager
competencies, since cost efficiency is an important
factor in the private sector. Our interviews also
revealed that nurse managers experienced in financial
mangement migrated from the public to private
sector, since Slovenian nurses in the public sector are
paid according to an extremely rigid payment system.
The results of the study also demonstrate the
difference between nurse managers at different
management levels. The difference in proficiency
in financial manager competencies could be
explained by greater autonomy and executive power
requiring a higher proficiency level in financial
management, and also by previous training. A study
conducted by Skela Savič et al. (2004) shows that
leadership performance in Slovenian hospitals
correlated with the type and extent of previous
training of employees. Nurse managers at the higher
organisational level received significantly more
training and education than other employees.
Training of employees in management in Slovenian
public sector hospitals is still not perceived as
a necessary investment to improve the work process
(Skela Savič, Robida, 2013). This is not only
a Slovenian phenomenon, but a global one (Backer et
al., 2012). New nurses, promoted from direct care
roles, are often not provided with any formal training
for their new role. Instead, they are expected to hit
the ground running. Therefore, the current, and future
management capacity should be enhanced by using
different forms of training, such as formal training
within the higher education curricula, in-service
training, informal training, and mentoring.
Nevertheless, management skills should be
considered a priority for high-quality health services,
since such services cannot exist without a skilled
management (Baker et al., 2012).
This study has some limitations. It is based on self-
assessment by nurse managers, which means that it is
subjective, and not externally validated. Furthermore,
the response rate was low. Future researchers should
638
Erjavec K, Starc J.
try to increase the response rate. However, despite
this limitation, the study has shown the practical
relevance of improving management in healthcare in
Slovenia and Eastern European countries which have
a similar healthcare system. It shows the importance
of management knowledge and skills in a profession
characterised by poor resources.
Conclusion
Nurse managers working in nursing homes assessed
themselves as being more competent than nurse
managers in hospitals. The largest proficiency gap
of nurse managers in nursing homes was found
in leadership and financial management
competencies. Public sector nurse managers assessed
themselves as being relatively less competent
in financial management than private sector
managers. Head nurses felt more competent
in financial management than nurse managers at
lower management levels. The reasons for nurse
managers’ differences in proficiency levels are the
degree of job security, autonomy, and support from
the healthcare team that they enjoy. Finally, a holistic
educational management framework is required to
provide a consistent approach to management
development for all healthcare employees.
Ethical aspects and conflict of interest
Ethics committee approval was not required. The
manager nurses were informed that their participation
in the study would be voluntary, and all data were
treated as confidential. The authors declare that the
study has no conflict of interest.
Author contribution
Conception and design (KE, JS), data analysis and
interpretation (KE), manuscript draft (KE), critical
revision of the manuscript (KE, JS), the final version
of the manuscript (KE, JS).
References
Baker S, Marshburn DM, Crickmore KD, Rose SB, Dutton K,
Hudson PC. What do you do? Perceptions of nurse manager
responsibilities. Nursing Management. 2012;43(12):24–29.
Bijelic N. Education and training of nurses in Slovenia.
Kranj: University of Maribor, FAO; 2010.
Cathcart EB, Greenspan M, Quin M. The making of a nurse
manager: the role of experiential learning in leadership
development. Journal of Nursing Management.
2010;18(4):440–447.
Chase L. Nurse manager competencies. Journal of Nursing
Administration. 1994;24(4 Suppl):56–64.
Chase LK. Nurse manager competencies [dissertation]. Iowa:
University of Iowa; 2010.
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
Chase LK. Are you confidently competent? Nursing
Management. 2012;43(5):50–53.
Costa Fernandes M, Sales da Silva LM, Magalhães Moreira
TM, Ferreira da Silva MR. Factors involved in the
management of nursing care: descriptive study. Online
Brazilian Journal of Nursing. 2013;12(3):522–533.
Hakim H. Not just for cars: lean methodology. Nursing
Management. 2014;45(3):39–43.
Jennings BM, Scalzi CC, Rodgers JD 3rd, Keane A.
Differentiating nursing leadership and management
competencies. Nursing Outlook. 2007;55(4):169–175.
Kang CM, Chiu HT, Hu YC, Chen HL, Lee PH, Chang WY.
Comparison of self-ratings on managerial competencies,
research capability, time management, executive power,
workload and work stress among nurse administrators.
Journal of Nursing Management. 2012;20(7):938–947.
Kantanen K, Kaunonen M, Helminen M, Suominen T. The
development and pilot of an instrument for measuring nurse
managers’ leadership and management competencies. Journal
of Research in Nursing. 2015;20(8):667–677.
Lega F, Prenestini A, Spurgeon P. Is management essential to
improving the performance and sustainability of health care
system and organizations? A Systematic review and a
roadmap for future studies. Value in Health. 2013;16(1
Suppl):S46–S51.
Lin LM, Wu JH, Huang IC, Tseng KH, Lawler JJ.
Management development: a study of nurse managerial
activities and skills. Journal of Healthcare Management.
2007;52(3):156–169.
Lorber M. Značilnosti in kompetence vodij v povezavi s
počutjem zaposlenih v zdravsteni negi [dissertation]. Maribor:
University of Maribor, Ekonomsko-poslovna fakulteta; 2015.
(in Slovenian)
Luo WY, Shen NP, Lou JH, He PP, Sun JW. Exploring
competencies: a qualitative study of Chinese nurse managers.
Journal of Nursing Management. 2016;24(1):E87–94.
McCallin AM, Frankson C. The role of the charge nurse
manager: a descriptive exploratory study. Journal of Nursing
Management. 2010;18(3):319–325.
Nurses and Midwives Association of Slovenia. [cited 2016
Aug 24] Available from: http://www.zbornica-
zveza.si/en/introduction
Pihlainen V, Kivinen T, Lammintakanen J. Management and
leadership competence in hospitals: a systematic literature
review. Leadership in Health Services (Bradford, England).
2016;29(1):95–110.
Pillay R. The skills gap in nursing management in South
Africa: a sectorial analysis: a research paper. Journal of
Nursing Management. 2010;18(2):134–144.
Prosser B, Olson RE. Changes in professional human care
work: the case of nurse practitioners in Australia. Health
Sociology Review. 2013;22(4):422–432.
Rigolosi ELM. Management and leadership in nursing and
health care. 3rd ed. New York: Springer Publishing
Company; 2013.
Patton MQ. Qualitative research & evaluation methods. 4th
ed. Los Angeles: Sage; 2015.
Skela Savič B, Pagon M, Lobnikar B. Leadership analysis in
Slovenian hospitals: who are successful leaders?
Organizacija. 2004;37(1):5–15.
Skela Savič B, Robida A. Capacity of middle management in
health-care organizations for working with people-the case of
Slovenian hospitals. Human Resources for Health.
2013;11:18.
639
Erjavec K, Starc J.
Slovenian National Institute for Public Health. EuroHealthNet
Roport: Championing a healthier and fairer Europe. [cited
2016 Jul 14] Available from:
http://eurohealthnet.eu/sites/eurohealthnet.eu/files/publication
s/EuroHealthNet%20Annual%20Report%202015-2016.pdf
Townsend K, Wilkinson A, Bamber G, Allan C. Accidental,
unprepared, and unsupported: clinical nurses becoming
© 2017 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2017;8(2):632–640
managers. The International Journal of Human Resource
Management. 2012;23(1):204–220.
Zavrl Džananović D. Patronažno varstvo Slovenije včeraj,
danes, jutri. Obzornik zdravstvene nege. 2010;44(2):117–125.
(in Slovenian)
640